Sex can be painful. This is true more often for women but it can also be painful for men. Repeated episodes (of painful sex) often establishes a cycle of pain, in which the anxiety and fear of pain leads to avoidance of the sexual activity that produces it. This results in arousal difficulties and failure to reach an orgasm, and consequently, may lead to negative impact on the couple's relationship.
This refers to pain in the female genitals that is associated with sexual intercourse. It usually occurs on penetration but it can also occur with genital stimulation. It is termed primary, when it has always occurred since the initial episode of sexual intercourse and secondary, when it occurs after a period of pain-free sexual intercourse.
Dyspareunia can be superficial or deep. The causes of superficial pain include :
* Lack of lubrication or dryness due to anxiety, failure to relax, menopause and unskilled foreplay.
* Infections like moniliasis, trichomoniasis, herpetic blisters and infected warts (human papilloma virus).
* Injury like episiotomy or tears in childbirth and following sexual assault.
* Foreign bodies like a forgotten tampon which has become infected.
* Rarely, cancer.
The causes of deep dyspareunia include :
* Cervical conditions like infections can lead to pain on deep penetration, a condition called “collision dyspareunia”.
* Uterine conditions like fibroids.
* Endometriosis, a condition in which the lining of the uterine cavity is found outside the uterus and/or in the muscle of the uterus. Penile pressure on an endometriotic spot or mass causes deep intense pain especially around the time of the periods.
* Pelvic inflammatory disease (PID) is an infection of the female genital organs in the abdomen, a common cause of which is chlamydia, especially when it is inadequately treated. The pressure of intercourse on the inflamed pelvic organs produces deep intense pain.
* Ovarian conditions like cysts. Pain can also result from a normal ovary which is unusually sited.
* Ectopic pregnancy is a pregnancy that is sited outside the uterine cavity. Pressure on it can be very painful and may cause it to rupture, resulting in a life threatening emergency.
Vaginal pain is the least common category of dyspareunia. This is because sensory nerves are only found in the lower third of the vagina. If this occurs, the pain is usually felt at the entrance to the vagina and the causes are the same as that of superficial pain.
The management of dyspareunia starts with history taking and physical examination, including a pelvic examination in which there is insertion of the doctor’s examining fingers into the vagina.
Depending on the cause(s), laboratory and imaging investigations may be carried out. Sometimes, surgical intervention may be necessary to elucidate and treat the cause for example, in the case of endometriosis, ovarian conditions or ectopic pregnancy.
The treatment is that of the physical cause such as hormones and lubricants in menopausal dryness, antimicrobials for infections, hormones and/or surgery for endometriosis, surgery for ectopic pregnancy.
Cognitive behavioural therapy may also be helpful. It is important that the woman understands and adapts to the problem. Many have been able to have a good quality sexual life with penetration. Successful treatment is much dependent on the woman having ownership and control of her sexual activity.
This is a condition when the muscles around the vagina contract tightly causing spasm, which can be quite painful. The spasm occurs in response to the vagina or vulva being touched prior to or at the time of penetration. Women with this condition cannot use tampons during the menses.
However, women with this condition can and do enjoy sexual pleasure, and are able to get an orgasm through masturbation, foreplay and oral sex. It is only when penetration is suggested or attempted that the vaginal muscles go into a spasm.
Vaginismus is a conditioned response in which there is an association of penetration with pain and fear. This psychological problem manifests itself in a physical way and is not uncommon among younger women.
There are many causes of the condition and it varies with different individuals. It may be related to superficial dyspareunia and its causes.
Some causes are physical such as infections of the female genital organs or bladder, injury, irritation from spermicides or condoms. It can occur after child birth or result from sexual assault or from a painful sexual encounter or examination. It can also be a side effect of medication or alcohol.
Psychiatric conditions like fear of pregnancy or that the vagina is too small, anxiety and depression are associated with vaginismus. Social causes include strict upbringing in which sexual matters are seldom or never discussed, inadequate or inappropriate sex education and relationship problems.
The management of the condition involves history taking and physical examination, especially a pelvic examination, if possible. The identification of the root cause is necessary for effective treatment. Physical conditions that cause or contribute to the condition need to be appropriately treated, such as the use of antimicrobials for infections.
A treatment programme is available for vaginismus, especially in instances when the cause is not physical but psychological. This involves the patient as well as her sexual partner. The goal of the programme is to achieve a situation where the patient feels that she is in control of her genitals.
Sex education and self exploration of the pelvic anatomy is vital. The patient learns how to control the vaginal muscle spasms while introducing trainers of gradually increasing sizes into the vagina.
The trainers can be fingers, tampons or specifically designed ones. The patient is in full control throughout this time, thus increasing her confidence about her own body and reducing any fears of sexual intercourse.
At some point in time, the patient will feel confident enough with the sharing of the introduction of trainers with her partner. This is followed by the insertion of the penis into the vagina with the patient in full control.
As the patient makes progress, she can then feel confident about transferring the control of penile insertion to her partner. The patient’s phobia also needs to be explored and treated.
Many women do not find the programme appealing when it is initially broached. However, if the programme is adhered to, there is almost 100% success if they continue with it.
An understanding partner is critical to successfully overcoming this problem.
Pain in Men
There are occasions when men experience pain during sexual intercourse. The usual causes are skin conditions affecting the penis like eczema and psoriasis. Occasional causes include phimosis, in which the foreskin cannot be fully retracted; fungal infection; prostatitis, in which there is inflammation of the prostate gland; thread of an intra-uterine contraceptive device (IUCD); a displaced IUCD in the vagina or Peyronie’s disease, a condition in which there is an abnormal upward penile curvature; or psychological causes.
After an evaluation, the treatment provided will be that of the cause.